Laserfiche WebLink
COMMENTS / CONDITIONS: <br />ooa I 6.5 <br />1 1 <br />; ACCOUNTING ONLY: AID# [ <br />1 1 PE CODES FEE INFO 1 AMOUNT REMITTED <br />3s-01 I I 14 61'00 <br />FAC-# <br />UMBER INVOICE CHECK#/CASH RECEIVED BY <br />Signed x". <br />WELL PERMIT APPLICATION FM UNIT IV <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />,.. ENVIRONMENTAL HEALTH DIVISION ("PHS-EHD") <br />(„ <br />)0 <br />.,,,-4' ,\%p 304s#. Weber, Third Floor, Stockton, CA., 95202 <br />, <br />Application is he,r tk.44(isSan Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with r - <br />San „Joaquin C/iib)d \Viapment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />D R 0 P E R TY Owneriilic 4 9-: -4 (.. i - k4 a e i I Address S..'4..V.....- City Zip Phone# <br />:-57 Contractor I/4 t..) Or. 14-.A Address 65,1)637 5/ City i'i?; AU., &Zip r1,4571 Lic#2444_Phone#9n• ,91- 9102 e.......1 <br />irieG Consultant / Sub Contractor/7'. 4,teci.. eq... -r Addressija-,c,59G f CI , City/Kul Phone#,Jen S72es4 Lids <br />GIS Coordinates: X V . Township Range Section <br /> <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER. OTHER") <br />opirSOIL BORING # Dfl <br />WELL # <br />'Other: <br />COMMENTS: <br />TYPE OF WELL CONSTRUCTION TYPE CONSTRUCTION SPECIFICATIONS <br />3 MONITORING a HOLLOW STEM DIA. OF BOREHOLE I. 2... MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA: <br />3 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />3 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS °HOSE <br />3 AIR SPARGE AfPUSH POINT GROUT SEAL PUMPED: a Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />FK.SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 3 STOVE PIPE <br />a OTHER: CONDUCTOR CASING PROPOSED' ( if YES. list specifications here): <br />COMMENTS: 5 .c., c- 4...-,.. t.. CY*. — Afe ,'•dli•-cii--.ft -&-- t- -76141.‘ a ••-oe-c s At "5' ?1 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITSI <br />i hereby certify that I nave prepared this application and that the work will be done in accoroance with San Joaquin County Ordinances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "/ certify that in the performance of the work <br />for which this permit is issued. I shall not employ persons subject to WORKMAN'S COMPENSATION Laws of California." Contractors hiring or sub- <br />zontracting signature certifies the following: "I certify tnat in the performance of tne work for wnic.n this Permit is issued. 1 shall employ persons subject to <br />WORKMAN'S COMP c 'T! .N Laws of California." <br />LI MUST ALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. 71 <br />Title CentSt-/-4....... I----- Date /..V.... -31 ••"" 9F <br />IV WORK PLAN. DATED /2 — /cf— FY <br />DEPARTMENT USE ONLY <br />Application Accepted By (A .-4AAA, CAA.-- <br />Grout Inspection By <br />Destruction inspection By <br />(1-‘'O (\ Co \..) . \-\ (209) 468-3450 <br />-- .4\'-NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />-,:.:0 30 \ ,q <br />Assessor's <br />0.4)64.54. ,A _L Cross Street Zip c--- Parcet# <br />---- <br />a DESTRUCTION (choose type below) <br />O OVER-BORE \._) <br />,..---.:,\ <br />O PRESSURE GROUT <br />.(-----. <br />SEE SITE MAP IN U <br />Date Issued <br />Date 1 IOC> Final Inspection By <br />Date <br />Area <br />Date <br />WELL Location #2 ea3 <br />UNIT IV - 5/99 /MI